Sunday, April 7, 2013

By: Dahlia Balaban BSc, MSc (future MD as of June 2013 and
Future Family Medicine resident as of July 2013)

As a first and second year medical student, I never thought I’d
go into Family Medicine-- I always saw myself as someone who loves the busy
hospital environment and thrives under pressure. Further, all my mentors were
internists who seemed to know everything there was to know about physiology,
pathophysiology, and treatments.

My career plans began to change during my third year, when I
made my hospital debut and found a Family Physician mentor who inspired me to
change my perspective. I quickly realized that it’s the patients and the
continuity of care that appeal to me most about medicine. I started to
appreciate that I’m a generalist who likes everything, and there’s nothing in
medicine that I would give up in order to specialize in any one area. It also
occurred to me that good Family Physicians have the potential to be the most
influential health care providers for their patients, since they are involved
in primary, secondary, and tertiary prevention. They have the ability to keep
their patients healthy, treat them when they’re sick, and prevent them from
getting re-admitted to hospital after discharge. Most importantly, they are
professional advocates who help their patients digest health-related
information and navigate the healthcare system.

Family Medicine has long been a popular career path for medical
students in Canada. Over the last few years, 30-35% of students graduating from
Canadian Medical schools chose Family Medicine as their first-choice
discipline. In 2012, McGill had the smallest percentage of its graduates
choosing Family Medicine (24.7%) while the Northern Ontario School of Medicine,
which was originally created to help produce primary care physicians to work in
under-serviced areas, had 53.7% of its graduates choosing it.
There are many reasons why Canadian medical graduates are drawn to family
medicine, and I will outline some of them below.

Top 10 Reasons to Pursue
Family Medicine Training in Canada (in no particular order):

1) Short, 2-year Training Program:

The College of Family Physicians of Canada (CCFP) was created
in 1967, and Family Medicine officially became a Canadian “specialty” in 2007.
Until the early 1990s, all medical school graduates in Canada did a one-year
rotating internship after which they could practice as General Practitioners
(GPs) or choose to pursue further specialization. Since then, Family Medicine
training in Canada has been 2 years (it is the only post-graduate medical
program that is shorter in Canada than in the US). Some have argued that 2 years is not enough for residents to gain the skills they need to practice
effectively as Family Physicians,
but the length of the program certainly makes it attractive for people who are
looking to finish their training and start practicing as soon as possible
(especially those who are worried about their loans or those who went to
medical school later in life). In any case, many people argue that the most
important learning in your career is not when you’re a resident, but when you
are starting out on your own in practice.

Although the residency is short, all the Family Physicians I
have spoken to who trained in Canada have told me that they transitioned well
into practice once they finished residency. However, many of them mentioned
that you never really feel ready, no matter how long you’ve trained and you
need just need to put yourself out there and take the plunge because you always
know more than you think you do.

In contrast to Family Medicine, all other residency training
programs in Canada require anywhere between 4-6 years, including Pediatrics
(minimum of 4 years to become a general Pediatrician), Internal Medicine (now requiring
a minimum of 5 years, even to become a General Internist), and ER (the Royal
College specialty requires 5 years of training). This means that Family
Medicine training is at least 2 years shorter than any other training program
in the country.

2) Salary:

Family Physicians in Canada work under a variety of
remuneration models, from fee-for-service to capitation to capitation with
shadow billing to salary (click for an example of this model in Ontario).
No matter the model, Family Physician salaries in Canada are competitive with
many other medical/non-surgical specialties (especially given the flexibility
of the job and the short length of the training program). For example, on
average, the gross fee-for service billings of Family Physicians in Canada is
similar to that of Psychiatrists (5 year program), Neurologists (5 year
program), Physiatrists (5 year program) and Pediatricians (4-5 year program).
Information on gross physician billings in Canada is collected by CIHI in the National Physician Database.

3) Portable:

While many specialists in Canada struggle to find work after finishing
their training (some needing to pursue multiple fellowships before they are
able to find employment), Family Physicians are in demand all over the country,
both in urban and rural settings. Residents often choose to locum for 1-2 years
after finishing their training so they can try out different work environments
and locations before deciding on where they want to permanently practice.

4) Flexible:

Family Physicians have the most flexibility in terms of how
much to work, when to work, and how to work. Most Family Physicians now work in
group practices that have daytime hours as well as evening and weekend hours,
and they can decide amongst themselves how to divide the responsibilities. Sole
practitioners generally have less flexibility, but they have the advantage of
being their own bosses so they can take time off as they want. Lastly, it’s
common in Family Medicine to do locums after finishing residency training, and
these are great when Family Physicians want to go on vacation.

5) Many ways to practice:

Family Physicians can choose to practice traditional,
office-based Family Medicine, but many choose to supplement traditional
practice with other types of work in order to keep things interesting (so
they’re not doing outpatient clinics 5-6 days a week). There is one
board-certified Family Medicine Fellowship in ER (1 extra year) in addition to
many other add-ons that are offered by the various residency programs. These
add-ons vary in terms of training time from 3 months to 1 year. While these
options are available, many Family Physicians can practice in each area without
any further training beyond the 2 years, as long as they feel comfortable/competent
and are able to find work. For example, Family Medicine residents can often get
jobs working in Emergency Departments without any extra training once they
finish residency. They can later challenge the ER fellowship exam after working
for a certain amount of time so they can get the professional designation and
have more employment opportunities.

Family Physicians can “sub-specialize” or practice in the
following areas, with or without extra training (this is not an exhaustive
list):

Addictions

Anesthesia

Breast Diseases

Care of the Elderly

Coroner

ER

HIV

Hospitalist

Global Health

Indigenous Health

OB (low-risk)

Palliative Care

Psychotherapy

Sports Medicine

Surgical Assist

Travel Medicine

Women’s Health

How Family Physicians practice generally depends on the needs
of the community in which they work, but Family Physicians are also portable
enough to move around until they find a community in need of the services they
want to offer.

6) Generalist, fast paced, diverse:

Primarily, Family Physicians are generalists. They are trained
to see people of all ages, including the healthy and the sick. On any given day
a Family Physician can see babies and elderly patients, do well patient visits,
follow up visits for chronic health problems, and assess acute illness. They
may do minor procedures and they may send a patient to the ER for a full
assessment. They provide primary care to patients with weird and wonderful
presentations. Family Physicians typically see 4-6 patients per hour so it
appeals to those who like busy, fast-paced environments. Further, some Family
Physicians have a general practice in addition to a more specialized practice
or hospital work. They may have multiple ways they practice within the same
day, within the same week, or within the same career. No matter what, there’s
no shortage of options for Family Physicians.

7) Family Physicians are integral to the medical system in
Canada:

For better or for worse, Family Physicians act as “gatekeepers” to all
specialists in Canada. This means that patients almost always need a referral
from a Family Physician (or ER doc) before they can see a Cardiologist, a GI
specialist, or a surgeon (to name a few) on an outpatient basis. This means
that there is always a lot of business for Family Physicians, and Family
Physicians are able to follow all aspects of their patients’ care.

8) Quality of residency programs

In Canada, all residency programs are tied to a university that
also provides undergraduate medical education. There are a total of 17 of these
in Canada (of which 3 are in Quebec and are exclusively Francophone). While
each of these programs may have multiple training sites, either urban or rural,
all sites are overseen by the main university and are held to very high
standards. This means that all Family Medicine training sites are considered to
be of comparable quality and boast high pass rates for the CCFP exam. You
really can’t go wrong by attending any one of the 17 Family Medicine training
programs, in any one of the available sites. Most residents end up choosing a
program based on location, type of program (eg. urban vs. rural, block vs.
horizontal curriculum), and unique aspects of the program (eg. Francophone vs.
bilingual vs. Anglophone).

9) Family Medicine = Primary Care:

Unlike in the US, Family Physicians provide almost all primary
care in Canada, along with nurse practitioners (in underserviced areas),
Pediatricians (who are now being encouraged to pursue subspecialties and act as
“consultants” instead of providing primary care), and General Internists (who
rarely provide primary care, as they’re trained to be hospitalists and
subspecialists). Family Medicine residents are the only ones who are trained in
all aspects of primary care (patients of all ages, preventive care, and
treatment of acute medical problems of all types). For those who feel strongly
about preventive medicine, patient advocacy and continuity of care, Family
Medicine is a great option.

10) Rural Family Medicine

Approximately 80% of Canadians live in urban areas, while the
other 20% are distributed in rural communities throughout the vast country (the
second largest in the world by area, after Russia).

Family Physicians who choose to practice in rural areas can
look forward to exciting opportunities, as they may be the only permanent
physicians there (specialists may only be available on certain days or in a
neighboring community). Rural Family physicians may do all the deliveries, work
in the ER, assist in surgeries, and act as hospitalists. The Family Physician
may be the first physician to assess and treat a trauma victim, and the
physician leading a resuscitation in the ICU. These activities are not thought
of as being part of bread-and-butter urban Family Medicine, but they are
certainly not unexpected for a Family Physician practicing in rural Canada.

Rural communities in Canada are generally considered
“underserviced” and physicians are often provided with great incentives to
permanently move there or to locum. Some of these communities are considered
“fly-in” (not accessible by land or water), and doctors will often be flown
into these communities to provide care on a temporary basis. This means that
even Family Physicians who primarily practice urban family medicine can
participate in the exciting aspects of rural practice.

Dahlia Balaban, MSc (@CdnMDStudent) is a Fourth year medical student and future Family Medicine resident at the University of Toronto in Canada with a special interest in medical education.

Match Day is once again upon the world of medicine, and we are eager to outline and track updates to 2012 match results for Family Medicine...

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